What Is It?

The average amount of time needed for a couple to conceive is six months. Most couples are able to conceive a pregnancy within one year of having frequent intercourse without using any birth control. Ten percent to 15 percent of couples will continue to have difficulty conceiving after one year of trying. When this happens, the couple is considered to have a problem with infertility.

Infertility can be caused by health problems in the man, the woman or both partners. In some infertile couples, no cause can be found to explain the problem. In approximately 20 percent of couples, more than one cause of the infertility is found. The cause of infertility occurs about as often in men as in women.

The natural process of aging significantly affects the ease with which a woman becomes pregnant. A woman’s ovaries and eggs become older as the woman ages so that ovulation, the process of forming and releasing an egg, becomes slower and less effective. The effect of aging begins even as early as age 30, but pregnancy rates are very low after age 44, even when fertility medications are used. Yet, approximately 20 percent of women in the United States have their first child at or after age 35.

Infertility itself does not produce any symptoms except for difficulty getting pregnant. The different causes of infertility are associated with various symptoms. Your medical history can help to explain what is causing the infertility. One or more of the following problems may exist:

• Infrequent ovulation (egg release from the ovary) accounts for 20 percent of female infertility problems. If you are not ovulating monthly, your periods will be infrequent or absent. Common causes of infrequent ovulation include body stresses such as eating disorders, unusually heavy exercise, rapid weight loss, low body weight and obesity. Some hormonal abnormalities such as thyroid problems, pituitary-gland problems, adrenal-gland problems and polycystic ovary syndrome can delay or prevent the ovaries from releasing an egg. Some symptoms that might suggest a hormone abnormality include unexpected weight loss or gain, fatigue, excessive hair growth or hair loss, acne and ovarian cysts. Cysts in the ovary can cause pelvic pain and also can interfere with the normal process of ovulation.
  
  
• Scarring in the fallopian tubes can prevent pregnancy because it stops the egg from traveling into the uterus. Fallopian-tube problems are the cause in approximately 30 percent of female infertility problems. Damage can be from a previous surgery, a previous ectopic (tubal) pregnancy, tubal scarring from endometriosis or from pelvic inflammatory disease. Pelvic inflammatory disease is a bacterial infection in the pelvis, frequently caused by sexually transmitted bacteria such as gonorrhea or chlamydia. It often scars, damages or blocks the fallopian tubes. A history of pelvic pain, with or without fever, may suggest a diagnosis of endometriosis or pelvic infection.
  
  
• Abnormalities in the shape or lining of the uterus account for almost 20 percent of female infertility problems. Fibroid tumors or uterine polyps sometimes result in heavy menstrual bleeding, pelvic pain or enlargement of the uterus. Scar tissue can develop within the uterine cavity as a complication of uterine infections, spontaneous or therapeutic abortions or surgical procedures such as a dilation and curettage (D&C). Such scar tissue can lead to infrequent periods, scanty menstrual flow. Sometimes, however, it doesn’t cause any noticeable changes in menstrual cycles.

An important first step in diagnosing female infertility is figuring out whether ovulation is occurring. When an egg is released, it causes a shift in the body’s sex hormones. This shift in sex hormones can be detected with these tests:

• The body’s early-morning core body temperature is affected by hormone shifts. By using a precise thermometer (called a basal body thermometer) to take your temperature every day when you first wake up in the morning, you will be able to detect a slightly higher temperature during the second half of your monthly cycle. This slight temperature change occurs after ovulation.
  
  
• An ovulation predictor test is an over-the-counter urine test that can predict egg release. The urine test checks for high levels of luteinizing hormone. A positive test near the middle of your cycle means it is likely you will have ovulated or are about to ovulate. The ovulation predictor test kit is available at most drug stores and pharmacies, and can be performed in your home.
  
  
• You also can examine your cervical-vaginal secretions at home. With careful instruction, some women are able to interpret changes in the appearance of the vaginal mucus and consistency of the cervix as a sign of hormone shifts that show ovulation has occurred.

Your doctor will review your complete medical history and conduct a thorough physical examination. A sample of mucus from your cervix and vagina may be tested for possible infection. If necessary, blood tests also can be used to confirm normal ovulation by measuring a high progesterone level in the later part of your menstrual cycle. Blood levels of two additional sex hormones, follicle stimulating hormone and estradiol, can help show that the ovaries are functioning well enough to release eggs. These blood tests usually are done at specific times in your menstrual cycle. Other blood tests may be needed to measure the function of your thyroid gland, your pituitary gland and your adrenal glands.

Other tests that are used to understand the cause of infertility examine the physical structure of pelvic organs.

• A hysterosalpingogram is an X-ray study done after a liquid X-ray dye is allowed to flow into your uterus through a slender catheter positioned just inside the cervix. The dye outlines the shape of your uterine cavity and reveals problems such as polyps, fibroid tumors or other variations in the shape of the inside of your uterus. The dye also flows through the fallopian tubes and can reveal problems such as partial or complete blockage.
  
• An ultrasound reveals the shape and size of the uterus, and gives some information about the uterine cavity or inner lining. However, this test cannot determine if the fallopian tubes are blocked. An ultrasound can identify the ovaries, their shape and size, and the presence of developing cysts. Ultrasound of the pelvis is very safe and does not involve the use of X-rays or dye.
  
• Hysteroscopy and laparoscopy are surgical procedures performed by a gynecologist. Both procedures use a small video camera to view the pelvic organs and special surgical instruments. Your gynecologist can use these instruments during a hysteroscopy to see the inside of your uterus and obtain biopsies or remove polyps, fibroids or scar tissue, or remove cysts from your ovaries. This procedure also can be used to reshape a deformed uterine cavity.

An explanation for infertility can be found in about 80 percent of cases of female infertility. Even when there is no medical explanation for a couple’s infertility, it’s still possible that the couple may conceive.

A fertility evaluation usually extends over several months because it requires numerous tests, and because some tests must be done during a specific time in the menstrual cycle. The treatments also require time, careful planning and repeated office visits. This can be an emotionally painful process since a considerable amount of time has been spent trying to become pregnant before making the decision to seek medical assistance. It is helpful for a woman who is awaiting a fertility evaluation to be prepared for a lengthy process of evaluation and treatment. Special counseling services are available to help cope with the problem of infertility and the process of evaluation and treatment.

You can optimize your chances of getting pregnant in a number of ways.

• Exercise moderately. If you are exercising so heavily that your menses are infrequent or absent, your fertility is likely to be impaired.
  
  
• Avoid extremes of weight. An optimum body mass index (BMI) is at least 20 and below 27.
  
  
• Avoid alcohol, smoking and excesses of caffeine (more than one cup of coffee per day) and avoid marijuana and cocaine.
  
  
• Review your medicines with your doctor. Drugs such as digoxin (Lanoxin); bodybuilding steroids; some drugs for treatment of thyroid conditions, depression, hypertension, seizure and asthma; and some prescription antacids can affect your ability to conceive or carry a normal pregnancy.

If you are thinking about parenthood, it is also important to optimize your health before you get pregnant by making sure that your immunizations are up to date, and by taking 0.4 milligrams (400 micrograms) of the vitamin folic acid every day, beginning at least one month before planning to conceive. Starting to take folic acid supplements a few months before conception greatly reduces the chance of abnormal development of the baby’s spinal column.

Treatment depends on the results of your infertility evaluation. Some causes of infertility have a specific treatment, such as surgery to remove a fibroid tumor or medicines to treat a thyroid problem.

Infertility associated with infrequent or absent ovulation often can be treated with various hormonal or fertility medications and special laboratory procedures. All fertility medications have potential side effects, and can cause complications or result in twin pregnancies or higher-order multiple pregnancies. The use of these medications and procedures requires the supervision of a physician who is an expert in their use.

• Clomiphene citrate (Clomid, Milophene, Serophene) is a medicine that stimulates the ovary to release one or more eggs. This medicine works indirectly by adjusting levels of your natural hormones.
  
  
• Injected forms of luteinizing hormone and follicle-stimulating hormone may be used when supervised by an infertility specialist. These medications encourage the ovaries to release more than one egg at a time. This is known as superovulation, or ovulation induction. These medicines are sometimes given after a course of treatment by a GnRH analogue that quiets down all natural hormone stimulation to the ovary in preparation for a precisely timed cycle of ovulation.
  

The released eggs will flow naturally into the uterus if the fallopian tubes are healthy. If not, other procedures can be done, including:

• Intrauterine insemination is a procedure in which sperm are inserted into the uterus directly. Semen is collected by the man, usually after he stimulates himself to ejaculate, and is inserted into the uterus using a special catheter or a syringe.
  
  
• In vitro fertilization (commonly called IVF) combines egg and sperm in a laboratory dish. Surgery is required to collect the eggs that your ovary has been stimulated to release. The eggs and sperm are combined in the laboratory, and the embryos are inserted into your uterus. Multiple embryos may be placed inside the uterus, but IVF does not guarantee that a pregnancy will result. Sometimes, more than one embryo implants itself in the uterus, which can result in twins, triplets or higher-order multiple pregnancies. This procedure requires treatment with hormones beforehand.
  
  
• Zygote intrafallopian transfer (ZIFT) or gamete intrafallopian transfer (GIFT) are variations of the surgical IVF procedure and require the presence of at least one healthy fallopian tube. In ZIFT, eggs are retrieved surgically and combined with sperm. The resulting embryos are placed in the fallopian tube. GIFT is when eggs and sperm are placed in the fallopian tube, allowing the eggs and sperm to combine naturally. As with IVF, these procedures require hormone pretreatment.

It is important for you to get counseling about all options for parenthood, including procedures for adoption. It is also important to know whether your health insurance will pay for infertility treatment.

Although it may be possible to become pregnant on your own after one year of trying to conceive, it is wise to speak with a physician after one year and possibly begin an infertility evaluation. If you are over 35 and want to become pregnant, you may want to consult your physician after four to six months of trying to conceive. Women over 40 should seek medical assistance sooner rather than later.

If you are undergoing fertility treatment, including taking medications to stimulate your ovaries, it is important for you to notify your infertility specialist about symptoms of pelvic pain and abdominal swelling. Unusually stimulated ovaries can lead to significantly enlarged ovaries and cause excessive accumulation of fluid in your pelvic area and abdomen.

The chance for any woman to have a successful conception and live birth depends on the cause of her infertility problem. Because of dramatic improvements in technology and pharmacy, it is possible for more than half of couples who seek infertility treatments to conceive.

Diseases and Conditions Center

All ArmMed Media material is provided for information only and is neither advice nor a substitute for proper medical care. Consult a qualified healthcare professional who understands your particular history for individual concerns.